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Care with Confidence

Your first client of the day says she has recently be diagnosed with fibromyalgia. Your next one says he suffers from arthritis. The third says she has a certain type of cancer. Many of your clients have health issues that they are communicating to you and many may consider you part of their health care team. But what exactly are these health issues and what effect can massage have on them? How do you know where to look for information? Your clients are asking you questions and you need to be ready.

The 2007 Annual Consumer Survey of the American Massage Therapy Association indicates that your number of clients is also increasing. More than 40 million American adults are getting a massage annually; 25 million more Americans each year are getting massages than 10 years ago. Fifty-five percent of doctors recommend massage therapy to their patients when asked, along with 48 percent of physical therapists and 44 percent of chiropractors. Many people still depend on massage for relaxation (22 percent); however, the trend (30 percent) is to use massage therapy “for medical purposes such as injury recovery, pain reduction, headache control, and for their overall health and wellness.”

Research is becoming increasingly important to massage therapy and to the advancement of the profession.1,7 Studies published by this research are creating a body of evidence for those in the profession to utilize. This information can help you improve your practice and help you work with your clients with various health conditions. For example, some diseases might have a contraindication for massage, while in other cases, massage might be considered highly beneficial. Massage therapy may be effective for back pain, migraine, carpal tunnel syndrome, anxiety, high blood pressure and to alleviate the side effects of cancer.2,4-6,8 Additionally, hospitals are using massage therapy with infants and pregnant women, for pre- and post-operative care, for physical therapy and for end-of-life care.

“Being a developmental specialist, I knew how important touch was for preterm infants,” says Maria Thillet, RN, BSN, an infant developmental specialist at Phoenix Children’s Hospital. “Using the literature to help support the concept helped me create an infant massage program at Phoenix Children’s Hospital,” she says.

The Spring 2006 “Research Literacy” column by Martha Brown Menard and Cynthia Piltch reviewed “Levels of Evidence” (www.massagetherapyfoundation.org/mtjresearchcolumn.html). This column explained systematic reviews, meta-analyses, experimental designs and descriptive and observational studies. But how do you actually find these evidencebased articles? Menard and Piltch suggested searching PubMed, or visiting public or university libraries. These are excellent suggestions. However, even if you find these articles, will they actually change your practice?

A recent study surveyed 160 massage therapists about the importance of research-based practice to chiropractors and massage therapists and found that 92 percent of massage therapists agreed with the statement “research adds credibility to my discipline.”7 However, massage therapists in this study were relying on handbooks, colleagues and websites rather than on evidence. Only 11.4 percent said they use research to actually change their practice.

The authors concluded that practitioners recognize the importance of research for clinical practice, and that “timely and appropriate strategies will help reduce practitioners’ fears, assist them in developing adequate skills, and allow them to use their research knowledge in daily practice.”

This article is designed to help do that. We present several strategies that will help you find the evidence, and reduce any fears you might have about the research process.

The Client Case

You’ve been massaging a middle-aged man with chronic lower back pain. You have been contemplating what modality will relieve his pain and would like to know if there is any evidence validating the use of massage for clients with chronic low back pain. Where should you start?

PUBMED

www.pubmed.govPubMed is always a great place to begin your research. It provides access to citations from biomedical literature and was developed at the National Library of Medicine. Much of PubMed’s content consists of information from the Medline database, which contains bibliographic citations and author abstracts from more than 5,000 biomedical journals published in the United States and 80 other countries; it contains more than 15 million citations, many of which you can access for free. (See pages 100 and 105 for more information about how to find articles for free and how to obtain them if there is a charge.)

To begin a search on PubMed, visit www.pubmed.gov. In the search box, type your terms—“back pain and massage.” At the time of this writing, the search returned 195 articles on the topic. The first one on the article list is, “Effectiveness of massage therapy for chronic, non-malignant pain: a review,” published in the June 4, 2007, issue of Evidence-based Complementary and Alternative Medicine.

This article states: “Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain.”

Sounds like an article you might want to read. It’s not only from an evidence-based journal, but it’s also free to read in PubMed.

You may also look at the pre-formatted PubMed searches available on the Massage Therapy Foundation website (www.massagetherapyfoundation.org/pubmedsearches.html). Scrolling through the list, you’ll fi nd one on back pain and massage. Clicking on this link launches an automated search in PubMed on the selected topic.

PubMed also has a separate subset for complementary and alternative medicine (CAM) therapy articles. You can limit your search results to this subset of articles by clicking on the “Limit Link.” Within this screen, there is a section called “Subsets” where you can select “Complementary.” Using this limit can help you isolate the articles about complementary and alternative medicine for a specific condition or disease.

Massage Therapy Research Database

www.massagetherapyfoundation.org/researchdb.htmlAnother great resource is the Massage Therapy Research Database. This database, provided by the Massage Therapy Foundation, contains more than 4,800 article citations. Beginning last year, additions to the database are of non-Medline indexed journals only. This is due to a new feature on the site that allows you to access live searches in PubMed. The following are some of the non-Medline indexed journals included in these updates: mtj, Journal of Bodywork and Movement Therapies and the Journal of Soft Tissue Manipulation.

A search of this research database for “back pain” and “massage” returned 83 article citations. (See the sidebar on page 100 for ways of obtaining the actual articles.)

The Cochrane Library

www.cochrane.orgThe Cochrane Library is recognized as the gold standard in evidence-based health care. It includes reliable evidence from Cochrane and other systematic reviews, clinical trials, and more. Full reviews are only available via subscription databases; however, the summaries are available for free on their site and often contain a good bit of information.

When we searched for massage and back pain we found a review titled “Massage for Low-Back Pain” by AD Furlan, et al.3 It states: “One of the oldest forms of health care now has Cochrane evidence of benefit. In the newly updated Cochrane review of massage for low back pain, there is now some evidence to show overall benefit. New, high-quality trials show that massage gives some relief from back pain that has continued for many weeks or months—and the benefit may continue at least a year after the course of massage is over. There is still not enough evidence about massage for acute back pain (back pain that started recently).” (See the sidebar on page 100 for information on obtaining the complete Cochrane review.)

NCCAM

www.nccam.nih.govThe National Center for Complementary and Alternative Medicine (NCCAM) is the federal government’s lead agency for scientific research on CAM therapies. A search of the site for back pain and massage yields a “Backgrounder” on massage therapy as CAM. While this is more of an overview of massage, there are helpful article references at the end of the page.

MEDLINEPLUS

www.medlineplus.govMedlinePlus directs you to information to help answer health questions. It combines the authoritative information from the National Library of Medicine, the National Institutes of Health (NIH), as well as other government agencies and health-related organizations.

It is consumer oriented so may not provide evidence-based resources; however, it is an excellent source for background information, and to educate yourself about your clients’ health conditions or diseases.

For example, a search for back pain on the website produced a number of results, including a page of links to various aspects of back pain. You can view them all by visiting www.nlm.nih.gov/medlineplus/backpain.html. It also includes sections on overviews, latest news, diagnosis/symptoms, treatment, prevention/screening and more.

National Guideline Clearinghouse

www.guideline.govThe National Guideline Clearinghouse is a resource that brings together evidence-based clinical practice guidelines in one convenient location. You can search the full text of available guidelines. For the case at hand, type “massage and back pain” in the search box. A number of results are presented, including a guideline entitled, “Low back: lumbar & thoracic (acute and chronic).” Within this document, massage is listed as an intervention for back pain.

Fee-Based Services

Other databases are available for a fee. However, your public or medical library may allow you to search these databases for free (see sidebar, page 100). Some options of these are:

Many of the resources outlined in this article may be new to you, but using them regularly will increase your ability to find what you need. If you need assistance in a particularly complex or difficult search, ask a librarian at your local public or university library or an affiliated health care organization library.

In the client case outlined in this article, the evidence showed that massage has proven benefits for those suffering chronic back pain. Using these resources can get you the evidence you need to make informed decisions about the practice you provide to your clients.

Increase in Articles Published About Massage in PubMed

From the 1980s to the 1990s there was a 50 percent increase in the number of articles written on massage indexed in PubMed, while from the 1990s until 2007 there was a 35 percent increase. Overall from 1980s to the 2000s there was a 102 percent increase.

How Do I Actually Find the Full Text fo an Article?

You have just completed a search and located a citation for a great article. You cannot find the full text online. Now what? There are several options available.

Public or university library — Contact your local public or university library and provide them with the citation for the article you wish to obtain. If they don’t have access to the article within their collection, they should be able to obtain the article for you from a library that does. Depending on your library’s policy, this may be a free service or available for a fee.

Affiliation with health care organization — If you have an affiliation with a health care organization such as a hospital, check to see if a medical library is available at the facility. The library staff can assist you in obtaining your needed article.

Loansome Doc—Loansome Doc is a service provided by the National Library of Medicine to help you locate an article from a medical library. Registration is required and can be completed at https://docline.gov/loansome/login.cfm. Local fees and methods of article delivery vary regionally. A nice feature of Loansome Doc is that it is connected to PubMed. So if you located an article in the PubMed database, you can order from the citation screen. Articles not available in PubMed can also be ordered. For more information on this service, please visit www.nlm.nih.gov/loansomedoc/loansome_home.html.

Purchase directly from publisher’s website — Often you can locate the full text of an article from the publisher’s website. However, this is usually the most costly method of obtaining an article and can vary from about $10 to $40 depending on the journal and the publisher.

Evidence-Based Practice: Why Should I Care?

Evidence-based practice began in clinical medicine as a concept to use the current best evidence in the literature to make health care decisions. This extends to massage therapists and their practice as clients often seek your assistance in relieving medical conditions. Knowing what evidence and research is available on the work that you do can provide you with the tools and knowledge needed to assist these clients.

For a step-by-step walk through of the searches outlined in this article, please visit www.amtamassage.org/mtj and click on the “online exclusives” link.

"AMTA and my chapter have already given me back so much that I cannot believe I ever considered another group."

—Chris B., AMTA member since 2012

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AMTA has long been the leading choice among massage therapists looking to establish themselves within the profession. We provide our members with the strongest benefits and promote massage therapy to the public and health care community.